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Category Archives: Medical Cardiac Arrest

Question: I was looking through Ask MAC and there are a few questions pertaining to cardiac arrest and shocks or no shocks of other responders. Are Paramedics are to include shocks delivered by the Fire Department prior to arrival in their treatment of a VSA patient?

My understanding from teachings in 2014/2015 is that if Fire delivered shocks we could count what they did. If they did not, we did not count their no shocks and conducted our own working towards the medical TOR which is also covered in the Summary of Changes document.

The question on ASK MAC seems to say if we trust the responders we can count everything I was hoping for a clarification that can be searched when the question comes up again.

Answer: Thank you for raising the important and sometimes confusing issue. Also thank you for looking through ASKMAC for what answers had already been provided.

In summary: If a first responder does not deliver any defibrillations, the paramedics are to complete their medical cardiac arrest directive in its entirety. If a first responder has delivered a defibrillation, the paramedics count the number of analysis/defibrillations completed as part of the medical directive and continue within the medical directive from that point.

To elaborate: This information was covered during the 2016-2017 Mandatory CME, but a refresher is a great idea. As stated in the Companion Document, as a general rule, Paramedics do NOT count pre-arrival interventions into their patient care. Care delivered prior to arrival can be “considered” and documented. However, in the setting of cardiac arrest where a medical termination of resuscitation (TOR) might apply, the Paramedics will complete three (3) rhythm interpretations/analyses themselves rather than “count” the number completed prior to their arrival.

A “first responder” is defined as any responder to a victim of out of hospital cardiac arrest who arrives ahead of paramedics and performs CPR and rhythm analyses using an AED in an organized and appropriate AHA-HSFO Guideline compliant fashion such that, upon arrival of paramedics, the paramedic is readily able to determine the number of analyses completed and the current sequence to follow.

SWORBHP Medical Council believes that ANY defibrillation delivered to a patient during a cardiac arrest resuscitation should be “counted” and “considered” as a contraindication to the application of the TOR.

If a defibrillation has been delivered to a patient by first responders, the TOR rule would not be considered. Any analyses (NSI and “shock delivered” analyses) may be “counted” or “considered” into the total number of analyses performed by paramedics upon their arrival and transport initiated/patch performed as per the Advanced Life Support Patient Care Standards Medical Cardiac Arrest Medical Directive. In essence, the care provided by the first responder should be considered as part of the number of analysis/defibrillation allowed within the cardiac arrest medical directive.

If no defibrillations/shocks were delivered ahead of paramedic arrival, paramedics must continue to obtain 3 additional analyses themselves resulting in No defibrillation/No Shock Advised (NSI) prior to patching to the BHP for consideration of Termination of Resuscitation (TOR)/pronouncement regardless of the number of NSI analyses obtained by first responders. Hence, the care provided by the first responder should not be considered as part of the number of analysis/defibrillation allowed within the cardiac arrest medical directive.

Question: With respect to the updated July 17, 2017 medical directive changes, are hangings, electrocution and anaphylactic cardiac arrests considered reversible causes of arrest, and therefore subject to consideration for early transport after 1 analysis, OR are they to be run as full medical cardiac arrests/4 analyses, regardless of whether defibrillation is indicated? Thank you.

Answer: The best treatment we can offer the majority of cardiac arrest patients is high quality CPR and early defibrillation which is best performed on scene. In the cases exemplified above, this statement holds true. With an anaphylaxis arrest, a dose of epi can be given. Beyond that, the best chance of survival for these patients is high quality CPR and defibrillation if required. If a time sensitive intervention can be performed to reverse the cause of the cardiac arrest that falls outside of paramedic scope of practice (ex – highly suspect tension pneumothorax as cause of cardiac arrest and PCP crew on scene), then the directive allows for early transport. With that being said, in the vast majority of cases it is extremely difficult to ascertain the exact cause of the cardiac arrest. The majority of cases will result in running the full medical cardiac arrest directive with a focus on high quality CPR +/- defibrillation.

Question: When running an ALS arrest where the patient is showing a PEA on the monitor with an accompanying high ETCO2, could we assume that this patient is in fact perfusing to some degree and pulses are just not palpable for various reasons (obesity, severe hypotension, etc.)?

Secondly, if the above assumption is correct, would it be prudent to stop CPR provided the ETCO2 remains high and administer Dopamine in hopes of increasing BP until pulses are palpable and BP obtainable; or should the vasopressor effects of Epinephrine be sufficient to facilitate this so just continue with Epinephrine q5 min and CPR?

Answer: Thank you for this insightful question where you have correctly identified that ETCO2 can be a valuable tool in cardiac arrest situations and may be a physiological markers of ROSC when the patient is hypoperfusing. The AHA has reviewed all of the relevant literature regarding ETCO2 in cardiac arrest and unfortunately, there is not enough evidence to support its sole use as an indicator for ROSC at this time.

You have also correctly identified that it can be very difficult to assess for a pulse in a patient who may be hypoperfusing. Studies have shown that healthcare providers often have difficulties ascertaining a pulse when one is present or believing one is present when it is in fact absent. Furthermore, with a focus on high quality CPR, we are seeing higher baseline ETCO2 levels in patients in cardiac arrest. As per Part 7, 3.3.1 of the 2015 AHA guidelines, ROSC is likely when an “abrupt increase in any of these parameters (ETCO2) is a sensitive indicator of ROSC” rather than the absolute value. The use of ETCO2 can be used in conjunction with other signs of life (pulse, breathing, movement etc.) to help determine ROSC. Furthermore, Part 5, 3.2 of the AHA guidelines state ”The healthcare provider should take no more than 10 seconds to check for a pulse and, if the rescuer does not definitely feel a pulse within that time period, the rescuer should start chest compressions” .

When faced with a situation where a rise in ETCO2 is noted and you are having difficulty determining a pulse, you can always ask your partner to confirm your findings at another site. If a pulse cannot be obtained, then resume CPR and follow your directive accordingly.

Question: After consistent review of the new ALS, I just came across something that I am hoping you may clarify for me. In regards to the Medical Cardiac Arrest directive, under the "clinical considerations," it states that under certain circumstances we transport after first rhythm analysis (and lists some examples). In the old ALS, one of these examples was "pediatrics" but now i notice that in the new ALS, also under clinical considerations, it mentions to plan for extrication and transport of pediatric cardiac arrest patients after 3 analyses. So, does this mean we do not transport after first rhythm analysis for pediatrics and must complete the full directive now?

Answer: The majority of peds cardiac arrest cases fall under ‘reversible causes’, so yes, go ahead and transport after one analysis (generally, these will present as Asystole or PEA). However, the directive allows for use of clinical judgment, case by case where you can stay on scene for peds VF/VT.

Very basically, the medical directive allows for transport after the 1st analysis (because most peds arrests are from reversible causes), OR stay on scene for 3 analyses (plus one immediately prior to transport) in cases of shockable rhythms.

Question: CPR guidelines: I understand that we start CPR with a patient less than 16 years old, heart rate less than 60 and signs of poor perfusion, agonal respirations as per the CPR guidelines. My question is if we have the same situation with an adult patient, what would be beneficial for this type of patient (CPR)?

Answer: This question was at least partially answered previously on ASK MAC with the following: “The provision of CPR is defined by the Heart and Stroke Foundation of Ontario Guidelines (HSFO) and not the Base Hospital. CPR should be initiated when a pulse is not present and a patient has no perfusion (apart from children). While it is tempting to begin CPR “early” in anticipation of an imminent arrest, it is also possible that patients in the condition you describe are maintaining some degree of cerebral perfusion and beginning active chest compressions would possibly be painful as well as asynchronous with the still contracting myocardium.”

There is no evidence to suggest benefit or harm for starting compressions in an adult patient with bradycardia, a pulse present and signs of poor perfusion. However compressions in this patient population are not recommended by the most recent AHA guidelines or the provincial standards so therefore we would not recommend compressions for the patient you describe. In this situation assisting the patient’s ventilation with BVM (i.e. the pulmonary part of CPR) as per the BLS Patient Care standards may be indicated. If the patient loses their pulse one would then move to the Cardiac Arrest medical directive and begin compressions.

Question: How many analyses would you perform on a patient who is VSA following a drowning. Is it considered special circumstances, should the patient be transported after one analysis? Or should we transport after the first rhythm that doesn't result in a defibrillation? How many shocks total if patient stays in a shockable rhythm (4 max or more)?

Answer: The question of cardiac arrest in a drowning population has been asked several times previously on the Ask MAC website. In short, patients who have arrested after drowning fall under the Medical Cardiac Arrest Directive. Nonetheless there is still a lot of controversy surrounding drowning and cardiac arrest. As such, please see the following answer:
The debate has centered upon whether the medical TOR has to be an arrest of suspected cardiac etiology in nature (as it says on the directive) or can it also include arrests felt to be asphyxial in etiology (such as drowning, hanging and electrocution- not an exhaustive list).

The concern of the Medical Council was how does the paramedic decide what arrest was caused by asphyxia vs. one of cardiac etiology when often details even on scene are difficult to obtain? You can imagine how many FAQ we would get as to what constitutes a cardiac arrest from a cardiac cause vs. an asphyxial!

The consensus from the SWORBHP Medical Council was for the paramedic to not attempt to break it down asphyxial vs. cardiac on scene… it gets too confusing.

We feel it is reasonable if all other criteria for TOR are met, patch to the BHP and let them be involved in the decision making. We did not want to have to place the paramedic in the difficult position of having to decide on scene- you have enough to do! If the BHP decides that a TOR is reasonable, then follow that protocol, and if not, transport the patient and continue resuscitation as directed.

As an aside, the support for this decision came from the previous ROC trial across North America which studied CPR rates. It was felt by ROC investigators that it was too difficult and unfair to make a paramedic decide on scene what caused the arrest, so arrests caused by asphyxia are treated the same as arrests caused by a presumed cardiac etiology. The Medical Council from SWORBHP thought this would be easier for all paramedics to adopt this same strategy for TOR.

As for a patient who remains in a shockable rhythm, as per the ALS PCS 4.0.1 “plan for extrication and transport for patients with refractory ventricular fibrillation and pediatric cardiac arrest (after 3 analyses), ensure quality CPR can be continued”. ACPs will patch for further direction (and prepare for transport as unlikely to receive pronouncement for patients in refractory VF) while PCPs will transport after 4th analysis or ROSC.

Question: As per the question posted Feb 5th, 2014, if the FD shocks a patient prior to our arrival, we may count that shock into our protocol assuming we deem their care to adhere to AHA guidelines. In that setting, do we dial up to our second shock dose, or start at our first shock dose and dial up appropriately after that?

Answer: Great question, as there are so many defibrillators now and different models it is hard to know which type the fire department is using, the specific model, and even how old and updated it is. The safest, and generic approach is to move forward with your full protocol, starting at the first shock dose, and keep going.

If you are very familiar with the fire defib unit, (you may work with them regularly, train with them, or teach them), and you are happy with the pad placement and care then absolutely dial up if you are sure patient needs the next dose level. Just document your actions and thinking, when dealing with unique situations as always, so we can follow your approach.

Question: After the recent introduction of Narcan for PCPs, I'm still a little confused about the role of Narcan in an arrest. The 2010 AHA Guidelines state there is no role for Naloxone in cardiac arrest but the 2015 Guidelines are less prohibitive, leaving some room for interpretation. I understand that where there is question whether the patient is pulseless or not, there is a role for naloxone in the setting of presumed opioid overdose but what is the direction of base hospital for the use of naloxone where there is definite absence of vital signs in the setting of a PCP-only arrest. Is it the expectation of the base hospital that PCPs attempt to administer naloxone at some point during that call? If so, when during the cardiac arrest protocol? On scene or en route to hospital?

Answer: Excellent question. As was mentioned in the recerts this year, the 2015 guidelines are less prohibitive. They are also a bit confusing as their recommendations differ based on the rescuer level and are a bit ambiguous in the summary vs the full report (see full explanation below, if interested). The issue, as you point out, is that naloxone (narcan) is an opiate receptor antagonist, and although it can rapidly reverse CNS and respiratory depression, will not sustain a life, as our current resuscitative measures do.

Bottom Line answer: When it comes to cardiac arrest, it is the expectation of base hospital, per the AHA guidelines, that paramedics focus on standard resuscitative measures. Standard resuscitative procedures like Bag Valve Mask ventilation will reverse the hypoxia that ultimately would have led to cardiac arrest from opiate misuse or overdose. In the setting of cardiac arrest where opioid misuse is the likely etiology, paramedics can consider a patch to the BHP for shared decision making in administering narcan when standard resuscitative measures are failing.

Explanation: As you eloquently put it, the AHA state that, “patients with no definite pulse may be in cardiac arrest or may have an undetectable or slow pulse. These patients should be managed as cardiac arrest patients.” This is the patient population where arguably narcan would have the most benefit. However, “standard resuscitative measures should take priority over naloxone administration (Class I, LOE C-EO)” as no matter what the cause of the arrest, they will help. Narcan administration will only help if these patients are in this “what-if” category of undetectable pulse.

This is also where the separation of recommendation of treatment based on level of training comes in. The AHA give “first-aid and other non-healthcare providers” the recommendation to administer naloxone (if it is available) as, “they are not instructed to attempt to determine whether an unresponsive person is pulseless.” Going on to say,“ Empiric administration of IM or IN naloxone to all unresponsive opioid-associated life-threatening emergency patients may be reasonable as an adjunct to standard first aid and non-healthcare provider BLS protocols (Class IIb, LOE C-EO)”. However, for trained healthcare providers, like paramedics, under the “ACLS Modification: Administration of Naloxone” section it states, “we can make no recommendation regarding the administration of naloxone in confirmed opioid-associated cardiac arrest. Patients with opioid-associated cardiac arrest are managed in accordance with standard ACLS practices”. This is in contrast with what was written in 2010, “Naloxone has no role in the management of cardiac arrest”. Back then, there was also no recommendations for first aid and non-healthcare provider support, as well as being before the widespread use and availability of community naloxone programs.

In summary, times are changing with regards to recommendations for management of opiate-associated toxicity. We now have a great adjuvant to our typical management of decreased LOC and decreased respiratory patients in addition to our typical supportive management. However, when it comes to cardiac arrest, it is the expectation of base hospital, per the AHA guidelines, that paramedics focus on standard resuscitative measures. Standard resuscitative procedures like Bag Valve Mask ventilation will reverse the hypoxia that ultimately would have led to cardiac arrest from opiate misuse or overdose. In the setting of cardiac arrest where opioid misuse is the likely etiology, paramedics can consider a patch to the BHP for shared decision making in administering narcan when standard resuscitative measures are failing.

Question: If a pediatric patient is significantly larger than expected (for example, a 6 year old female who weighs 120lbs), do we still use the pediatric dosing chart OR calculation OR adult settings? Personally, if I'd done this call today, I probably would have chosen to use the pediatric calculations of 2J/kg then 4J/kg etc.

i.e.: If using peds dosing chart, this 6 year old would only get a shock of 50J 100J 100J 100J

i.e.: If using peds calculation, she would receive 110J 220J 220J 220J

i.e.: If using adult settings, she would receive 200J 300J 360J 360J

The patient in question is not your average sized peds patient for whom the age based peds dosing chart was developed. Any time there is a discrepancy between the actual and calculated weight of a pediatric patient (be it over or under) choosing to use the peds calculation would result in a more accurate dosage of electricity being delivered. However, in this case, given the importance of early defibrillation, a lower dose of electricity would be better than a delayed dose of electricity due to the time required to calculate the proper dose based on weight or needing to reference additional dosing cards.

Key message being early defibrillation is more important than delayed defibrillation.

It also should be of note that the maximum dose of electricity delivered should not exceed that of the adult dose.